Teaching Hospitals In Ontario Research Articles

Analysis of Resident and Attending Physician End-of-Rotation Changeover Days and Association With Patient Length of Stay

End-of-rotation resident physician changeover is a key part of postgraduate training but could lead to discontinuity in patient care. To test whether patients exposed to end-of-rotation resident changeover have longer hospital stays and whether this association is mitigated by separating resident and attending changeover days. This retrospective cohort analysis included adult patients admitted to general internal medicine. The changeover day was the same day (first Monday of month) for both resident and attending physicians until June 30, 2013 (preseparation period), and then intentionally staggered by 1 or more days after July 1, 2013 (postseparation period). This was a multicenter analysis at 4 teaching hospitals in Ontario, Canada, from July 1, 2010, to June 30, 2019. Data analysis was conducted from July 2022 to January 2023. Patients were classified as changeover patients if the first Monday was a resident changeover day and as control patients if the first Monday was not a resident changeover day. The primary outcome was length of hospital stay. Secondary outcomes were transfer to critical care, in-hospital death, and rate of discharge per 100 patients on the index day. Of 95 282 patients. 22 773 (24%; mean [SD] age, 67.8 [18.8] years; 11 156 [49%] female patients) were exposed to resident changeover, and 72 509 (76%; mean [SD] age, 67.8 [18.7] years; 35 293 [49%] female patients) were not exposed to resident changeover. Exposure to resident changeover day was associated with a slightly longer hospital stay compared with control days (0.20 [95% CI, 0.09-0.30] days; P < .001) and decreased relative risk of patient discharge on the index day (relative risk, 0.92; 95% CI, 0.86-1.00; P = .047). These associations were similar in the preseparation and postseparation periods. Resident changeover was not associated with an increased risk of transfer to critical care or in-hospital death. In this study, a small positive association between exposure to resident physician changeover and length of hospital stay as well as reduced rate of discharge was found. These findings suggest that separating changeover days for resident and attending physicians may not significantly change these associations.

Addressing Transition To Work Needs For Men and Women Following Traumatic Brain Injury and COVID-19

<h3>Research Objectives</h3> To investigate across sex (i.e., biological attributes) and gender (i.e., roles and responsibilities), the support services and workplace accommodation needs for men and women with traumatic brain injury (TBI), and the impact of COVID-19 on work and mental well-being. <h3>Design</h3> A cross-sectional study design with an online survey. Descriptive and regression analyses were completed for sex and gender differences. Open-ended responses were analyzed through a content analysis approach. <h3>Setting</h3> Research Electronic Data Capture application of a research teaching hospital in Ontario, Canada. <h3>Participants</h3> Adult persons with TBI were recruited nationally. <h3>Interventions</h3> Not applicable. <h3>Main Outcome Measures</h3> Differences between men and women in domains of quality of life after brain injury-overall scale (QOLIBRI-OS), health support service needs, workplace accommodations, and change in employment status and mental health due to COVID-19. <h3>Results</h3> Thirty-two persons with TBI (62% women; 38% men) completed the study. The most needed services by women and men were physiotherapy, occupational therapy, and counselling services. The most needed workplace accommodations for men and women were modified hours/days and modified/different duties. Women expressed needing help with housekeeping and caregiving to transition to work effectively. Women also scored poorer on the daily activity domain of the QOLIBRI-OS. Women were more likely to experience no change in employment status because of COVID-19, whereas men expressed concern over job security and finances. Mental well-being was a concern for both men and women. <h3>Conclusions</h3> Results revealed noteworthy differences between men and women's needs post-TBI, including during the pandemic. Rehabilitation professionals can better support men and women with TBI through awareness of their specific workplace accommodation needs. <h3>Author(s) Disclosures</h3> No conflict to disclose.

Cerebral Perfusion in Hemodialysis Patients: A Feasibility Study.

Background:Patients on hemodialysis (HD) are known to exhibit low values of regional cerebral oxygenation (rSO2) and impaired cognitive functioning. The etiology of both is currently unknown.Objective:To determine the feasibility of serially monitoring rSO2 in patients initiating HD. In addition, we sought to investigate how rSO2 is related to hemodynamic and dialysis parameters.Design:Prospective observational study.Setting:Single-center tertiary academic teaching hospital in Ontario, Canada.Participants:Six patients initiating HD were enrolled in the study.Methods:Feasibility was defined as successful study enrollment (>1 patient/month), successful consent rate (>70%), high data capture rates (>90%), and assessment tolerability. Regional cerebral oxygenation monitoring was performed 1 time/wk for the first year of dialysis. A neuropsychological battery was performed 3 times during the study: before dialysis initiation, 3 months, and 1 year after dialysis initiation. The neuropsychological battery included a traditional screening tool: the Repeatable Battery for the Assessment of Neuropsychological Status, and a robot-based assessment: Kinarm.Results:Our overall consent rate was 33%, and our enrollment rate was 0.4 patients/mo. In total 243 rSO2 sessions were recorded, with a data capture rate of 91.4% (222/243) across the 6 patients. Throughout the study, no adverse interactions were reported. Correlations between rSO2 with hemodynamic and dialysis parameters showed individual patient variability. However, at the individual level, all patients demonstrated positive correlations between mean arterial pressure and rSO2. Patients who had more than 3 liters of fluid showed significant negative correlations with rSO2. Less cognitive impairment was detected after initiating dialysis.Limitation:This small cohort limits conclusions that can be made between rSO2 and hemodynamic and dialysis parameters.Conclusions:Prospectively monitoring rSO2 in patients was unfeasible in a single dialysis unit, due to low consent and enrollment rates. However, rSO2 monitoring may provide unique insights into the effects of HD on cerebral oxygenation that should be further investigated.Trial Registration:Due to the feasibility nature of this study, no trial registration was performed.

Explicit Dialogue About the Purpose of Hospital Admission Is Essential: How Different Perspectives Affect Teamwork, Trust, and Patient Care.

The authors previously found that attending physicians conceptualize hospital admission purpose according to 3 perspectives: one focused dominantly on discharge, one on monitoring and managing chronic conditions, and one on optimizing overall patient health. Given implications of varying perspectives for patient care and team collaboration, this study explored how purpose of admission is negotiated and enacted within clinical teaching teams. Direct observations and field interviews took place in 2 internal medicine teaching units at 2 teaching hospitals in Ontario, Canada, in summer 2017. A constructivist grounded theory approach was used to inform data collection and analysis. The 54 participants included attendings, residents, and medical students. Management decisions were identified across 185 patients. Attendings and senior medical residents (second- and third-year residents) were each observed to enact one dominant perspective, while junior trainees (first-year residents and students) appeared less fixed in their perspectives. Teams were not observed discussing purpose of admission explicitly; however, differing perspectives were present and enacted. These differences became most noticeable when at the extremes (discharge focused vs optimization focused) or between senior medical residents and attendings. Attendings implicitly signaled and enforced their perspectives, using authority to shut down and redirect discussion. Trainees' maneuvers for enacting their perspectives ranged from direct advocacy to covert manipulation (passive avoidance/forgetting and delaying until attending changeover). Failing to negotiate and explicitly label perspectives on purpose of admission may lead to attendings and senior medical residents working at cross-purposes and to trainees participating in covert maneuvers, potentially affecting trust and professional identify development.

Investigating the relationship between vancomycin-resistant Enterococcus control practices and the incidence of health care–associated Clostridioides difficile infections in Ontario

We evaluated the impact of discontinuing vancomycin-resistant Enterococcus (VRE) screening and use of contact precautions on the incidence of health care-associated Clostridioides difficile infection (HA-CDI) in acute teaching hospitals in Ontario, Canada. Among hospitals that stopped VRE screening and contact precaution measures, there was a significant change in HA-CDI rates after the discontinuation of practices (incidence rate ratios, 1.11; 95% confidence interval, 1.01-1.22). No change in rate was observed among hospitals that continued VRE control practices. Screening and use of contact precautions for VRE may provide hospitals additional advantages for broadened HA-CDI control and prevention.

Health Centre Staff Are Satisfied with Librarian-Mediated Search Services, Especially When Librarians Follow Up

A Review of: McKeown, S., Konrad, S.-L., McTavish, J., &amp; Boyce, E. (2017). Evaluation of hospital staff’s perceived quality of librarian-mediated literature searching services. Journal of the Medical Library Association, 105(2), 120-131. http://dx.doi.org/10.5195/jmla.2017.201&#x0D; Abstract&#x0D; Objective – To determine the effects of the professional designation and communication method on clinical, educational, and research activities and related users’ reported satisfaction with and perceived quality of a librarian-mediated literature searching service.&#x0D; Design – Online survey.&#x0D; Setting – A large teaching hospital in Ontario, Canada. Subjects – 237 health sciences centre staff who were requesting librarian-mediated literature searching over a one-year period.&#x0D; Methods – From February 1, 2014 to January 31, 2015, one-third of the health centre staff members requesting searching services, representing a systematic sample of the user group, were invited to participate in the survey. The survey centred on questioning participants on a critical incident, which, according to the critical incident technique, is an actual event upon which recollections are made, rather than hypothetical situations. In the case of this study, the critical incident was the service they received upon requesting literature searching by a librarian who was blinded concerning the originator of the request. With a 71% response rate, the researchers received 137 responses to the survey by health sciences staff. Participants were asked how many literature searches they had requested in the previous year, the reason they requested the service, how they submitted the request, and whether the librarian followed up for further clarification of their need. They also reported on the relevance of the results and their method of delivery, along with their perceptions of the overall quality of the service.&#x0D; Main Results – The results came from 137 completed surveys, for a 71% response rate. Physicians, nurses, and allied health professionals comprised 85% of the responses, at 35%, 27%, and 23% respectively. Scientists, researchers, research coordinators, and other staff made up the remainder of responses. Responses indicated frequent search requests, with the average number of searches being five, and 68% of respondents reported searching for the information themselves before contacting the library for assistance. Most searches were for research/publishing (34%) and teaching/training (20%). Requests were submitted via email (44%), online form (32%), in person (17.5%), and phone (6.5%), and most respondents rated themselves extremely satisfied (54%) or very satisfied (42%). Most respondents (72%) reported that the librarian followed up for further clarification of the request, and staff who received follow-up rated themselves extremely satisfied at a significantly higher rate than those who did not (p=0.002). Respondents whose request was submitted verbally (i.e., by phone or in person), in comparison with those whose request was submitted by email or online form, rated themselves extremely satisfied at a significantly higher rate (p=0.004) and rated the quality of results as excellent at a significantly higher rate (p=0.005).&#x0D; Conclusion – The need for comprehensive and expert searching when publishing or completing research and the availability of easy to use point-of-care resources may be why librarian-mediated literature searching was used for research and publishing at a rate much higher than for patient care. In addition, the fact that the institution was also engaged in efforts toward evidence-based standardization of care and electronic health records during that year may have also affected results. While satisfaction with the service was higher for those communicating verbally with a librarian, it is unclear whether this was caused by other factors or differences between staff members who engage in phone or in-person communication and those who submit forms and online requests. Because following up was correlated with higher satisfaction, adjustments in service encouraging librarians to follow up are recommended. Following up in person and via phone may help further.

Non-essential blood tests in the intensive care unit: a prospective observational study

Non-essential blood testing in the acute care setting can be a prominent source of morbidity, patient discomfort, increased workload for the healthcare provider, and wasteful spending. The magnitude of such non-essential blood testing has not been well described. We aimed to measure the extent of unnecessary blood testing in a 33-bed intensive care unit (ICU) at a tertiary-care teaching hospital in Ontario, Canada. Over a period of four weeks, all ICU attending physicians were asked to select, from a comprehensive list, blood tests that they deemed essential to the appropriate care for each of their patients on the following day. The actual tests processed on the following day were recorded. Descriptive statistics were used to determine what proportion of all processed tests were deemed essential blood tests. The association between patient characteristics and the total cost of unnecessary tests was assessed using the Wilcoxon rank-sum test and the Spearman correlation coefficient, as appropriate. Nine attending physicians provided input for a total of 81 patient days. In 65 (80%) of these days, at least one test was considered non-essential. Physicians deemed only 338 (48.7%) of 694 processed blood tests as essential, which amounted to $2,243.41 (46.0%) out of an overall cost of $4,882.11. Patients' age, sex, mechanical ventilation status, and treatment with vasoactive drugs on the study day were not associated with the number of non-essential tests. Attending physicians deemed a substantial proportion of the blood tests processed in a tertiary care ICU setting as unnecessary. Furthermore, the non-essential tests incurred substantial additional cost. Further work is required to gain a better understanding of the underlying factors contributing to these wasteful practices.

Hysterectomy: Technicity Index and Safety at a Tertiary Care University Affiliated Teaching Hospital in Ontario

Hysterectomy: Technicity Index and Safety at a Tertiary Care University Affiliated Teaching Hospital in Ontario

Ethnographic Investigation of Oral Care in the Intensive Care Unit.

Oral care plays a clear and important role in the prevention of ventilator-associated pneumonia. However, few studies have explored the actual work of oral care by nurses in the intensive care unit. To explore intensive care nurses' knowledge of and experiences with the delivery of oral care to reveal less visible aspects of this work. In an institutional ethnography, go-along and semistructured interview methods were used to explore the oral care practices and perspectives of 12 bedside nurses and 12 interprofessional (intensivist, allied health, and management) participants in an intensive care unit at a large urban teaching hospital in Ontario, Canada. Nurses described how obstacles frequently inhibited the delivery of oral care. Technical barriers included oral crowding with tubes and aversive responses by patients, such as biting. Contextual impediments to oral care included time constraints, lack of training, and limited opportunities for interprofessional collaboration. A key discovery was the presence of an informal unit-based nursing curriculum, whereby nurses acquired strategies to overcome barriers to oral care. Although the nurses did extensive problem solving in providing oral care, the interprofessional participants had limited knowledge of how oral care was accomplished. These data suggest the complexity of performing oral care in intensive care is underestimated and perhaps undervalued. Future research is needed to address technical and contextual barriers to optimize current guideline expectations for the provision of regular and effective oral care.

Facilitators and barriers to application of the Canadian C-spine rule by emergency department triage nurses

ObjectivesWe recently conducted a multicentre implementation study on the use of the Canadian C-Spine Rule (CCR) by emergency department (ED) nurses to clear the c-spine in alert and stable trauma patients (n = 4506). The objective of this study was to conduct a survey of nurses, physicians, and administrators to evaluate their views on the facilitators and barriers to the implementation of the CCR. MethodsWe conducted both a paper-based and an electronic survey of the three different ED hospital staff groups of nine large teaching hospitals in Ontario, including six regional trauma centres. The content of this survey was informed by a qualitative evaluation of the opinions of the study nurses who had participated in the validation study. Results57.5% (281/489) ED triage nurses, 50.2% ED physicians, and 82.8% of administrators responded. Nurse responses most often showed support from manager/educators and teamwork between physicians, nurses, and managers as being important facilitators to the use of the CCR. Physician responses most often identified the importance of a nurse leader/champion/educator, and presence of strong physician leaders. Administrator responses indicated the importance of nurse educators/champions, nurse engagement, and educational support. Barriers indicated by all three groups included busy department, lack of physician support, and lack of nursing support. ConclusionsBringing about change in clinical practice is complex. Strong leadership, effective communication, and senior physician buy-in appear to be very important. Identification of system-specific barriers and facilitators are important components of successful knowledge translation.

“They Have to Adapt to Learn”: Surgeons’ Perspectives on the Role of Procedural Variation in Surgical Education

Clinical research increasingly acknowledges the existence of significant procedural variation in surgical practice. This study explored surgeons' perspectives regarding the influence of intersurgeon procedural variation on the teaching and learning of surgical residents. This qualitative study used a grounded theory-based analysis of observational and interview data. Observational data were collected in 3 tertiary care teaching hospitals in Ontario, Canada. Semistructured interviews explored potential procedural variations arising during the observations and prompts from an iteratively refined guide. Ongoing data analysis refined the theoretical framework and informed data collection strategies, as prescribed by the iterative nature of grounded theory research. Our sample included 99 hours of observation across 45 cases with 14 surgeons. Semistructured, audio-recorded interviews (n = 14) occurred immediately following observational periods. Surgeons endorsed the use of intersurgeon procedural variations to teach residents about adapting to the complexity of surgical practice and the norms of surgical culture. Surgeons suggested that residents' efforts to identify thresholds of principle and preference are crucial to professional development. Principles that emerged from the study included the following: (1) knowing what comes next, (2) choosing the right plane, (3) handling tissue appropriately, (4) recognizing the abnormal, and (5) making safe progress. Surgeons suggested that learning to follow these principles while maintaining key aspects of surgical culture, like autonomy and individuality, are important social processes in surgical education. Acknowledging intersurgeon variation has important implications for curriculum development and workplace-based assessment in surgical education. Adapting to intersurgeon procedural variations may foster versatility in surgical residents. However, the existence of procedural variations and their active use in surgeons' teaching raises questions about the lack of attention to this form of complexity in current workplace-based assessment strategies. Failure to recognize the role of such variations may threaten the implementation of competency-based medical education in surgery.

The influence of frontline manager job strain on burnout, commitment and turnover intention: A cross-sectional study

BackgroundThe frontline clinical manager role in healthcare is pivotal to the development of safe and healthy working conditions and optimal staff and patient care outcomes. However, in today's dynamic healthcare organizations managers face constant job demands from wider spans of control and complex role responsibilities but may not have adequate decisional authority to support effective work performance resulting in unnecessary job strain. Prolonged job strain can lead to burnout, health complaints, and increased turnover intention. Yet, there is limited research that examines frontline manager job strain and its impact on their well-being and work outcomes. The substantial cost associated with replacing experienced managers calls attention to the need to address job strain in order to retain this valuable organizational asset. ObjectivesUsing Karasek's Job Demands-Control theory of job strain, a model was tested examining the effects of frontline manager job strain on their burnout (emotional exhaustion and cynicism), organizational commitment and ultimately, turnover intentions. DesignSecondary analysis of data collected in an online cross-sectional survey of frontline managers was conducted using structural equation modeling. ParticipantsAll 500 eligible frontline managers from 14 teaching hospitals in Ontario, Canada, were invited to participate and 159 responded for a 32% response rate. MethodsParticipants received an email invitation with a secure link for the online survey. Ethics approval was obtained from the university ethics board and the respective ethics review boards of the 14 organizations involved in the study. The model was tested using path analysis techniques within structural equation modeling with maximum likelihood estimation. ResultsThe final model fit the data acceptably (χ2=6.62, df=4, p=.16, IFI=99, CFI=.99, SRMR=.03, RMSEA=.06). Manager job strain was significantly positively associated with burnout which contributed to both lower organizational commitment and higher turnover intention. Organizational commitment was also negatively associated with turnover intention and there was an additional direct positive relationship between job strain and turnover intention. ConclusionsPreliminary support was found for a model showing that manager job strain contributes to burnout, reduced organizational commitment and higher turnover intentions. Findings suggest that organizations need to monitor and address manager job strain by ensuring managers’ role demands are reasonable and that they have the requisite decision latitude to balance role demands.

Avoiding prepositional pile-up.

None

Failure to cope: the hidden curriculum of emergency department wait times and the implications for clinical training.

The study explored optimal intraprofessional collaboration between physicians in the emergency department (ED) and those from general internal medicine (GIM). Prior to the study, a policy was initiated that mandated reductions in ED wait times. The researchers examined the impact of these changes on clinical practice and trainee education. In 2010-2011, an ethnographic study was undertaken to observe consults between GIM and ED at an urban teaching hospital in Ontario, Canada. Additional ad hoc interviews were conducted with residents, nurses, and faculty from both departments as well as formal one-on-one interviews with 12 physicians. Data were coded and analyzed using concepts of institutional ethnography. Participants perceived that efficiency was more important than education and was in fact the new definition of "good" patient care. The informal label "failure to cope" to describe high-needs patients suggested that in many instances, patients were experienced as a barrier to optimal efficiency. This resulted in tension during consults as well as reduced opportunities for education. The authors suggest that the emphasis on wait times resulted in more importance being placed on "getting the patient out" of the ED than on providing safe, compassionate, person-centered medical care. Resource constraints were hidden within a discourse that shifted the problem of overcrowding in the ED to patients with complex chronic conditions. The term "failure to cope" became activated when overworked physicians tried to avoid assuming care for high-needs patients, masking institutionally produced stress and possibly altering the way patients are perceived.

129: Diagnosing Fetal Alcohol Spectrum Disorder, the Need for Genetic Testing: A Pilot Study

Fetal Alcohol Spectrum Disorder (FASD) has no specific diagnostic marker, and the facial features and growth restriction found in the full Fetal Alcohol Syndrome are found only in a small percentage of children diagnosed within the Fetal Alcohol Spectrum. The presentation of FASD often overlaps with genetic syndromes. Thus, a genetic opinion is frequently requested in the assessment of a child with suspected FASD. To study the outcome of genetic assessments of 220 children and youth referred to a FASD clinic between 2009 and 2013. Prospective study design. 220 children and youth, aged 18 months to 23 years. FASD clinic in a large teaching hospital in Ontario. Data from the medical records were abstracted, entered onto a standard study pro forma, recorded in an Excel spreadsheet, and analyzed using simple frequency analysis. Sixty-eight percent of children and youth assessed in the clinic were diagnosed with Fetal Alcohol Spectrum Disorder. Twenty-eight percent had at least one facial feature of the full Fetal Alcohol Syndrome including thin upper lip, smooth philtrum, or short palpebral fissures. Only 4% had all of the three facial features. The most common alternative diagnosis was a chromosome disorder including Fragile X, 22q11.2 deletion, Williams Syndrome and others, representing 11.2% of the FASD referrals. Genetic assessment was of particular value in excluding other diagnoses and providing information to caregivers. Structural malformations were not common in the group overall, and some previously reported diagnostic signs were not found to be reliable markers of FASD. Chromosome disorders showed phenotypic overlap with FASD, and are an important differential diagnosis. The study findings support a large multi-centre project.

The first 10 years experience with genetic testing (GT) for BRCA1/2 mutations in a publicly funded program at a tertiary care teaching hospital in Ontario, Canada.

1550 Background: Publicly funded testing for BRCA1/2 mutations in Ontario has been available for high-risk individuals since 2000. The criteria are based on personal and/or family cancer history and ethnicity. We reviewed the results of the first 10 yrs of testing at our institution, a regional cancer centre in an academic, tertiary care teaching hospital. Methods: This REB-approved, retrospective study included individuals who had GT from 2001-2011. Sociodemographic, clinical, and GT results were collected. Results: 2,305 individuals met criteria and underwent GT between Jan. 2001and Dec. 2011. Of all tested subjects, 93% were female, median age was 55 yrs., 23% were of Ashkenazi Jewish (AJ) ancestry and 80% lived in an area with family income $50-100K/yr. BRCA1/2 mutations were present in 16%, 8% had unclassified variant (UCV), 76% had normal sequence. We excluded 460 individuals who had predictive GT for a familial mutation, and results are shown in the Table. For each carrier, an average of four additional relatives had GT. The most common criteria for GT was at least three cases of ovarian or breast cancer at any age on the same side of the family. BRCA mutations were most common among those AJ, Italian, Asian Oriental and English ancestry. Wait time for GT result improved from 107 wks. in 2001 to 8 wks. in 2011. Conclusions: In our tested population, the prevalenceof BRCA1/2 mutations was high. Over time wait times improved and more relatives were tested. [Table: see text]

Understanding the Patients' Perspective of Emotional Support to Significantly Improve Overall Patient Satisfaction

This article presents the results of a research study that laid out important considerations for organizations to improve their patient satisfaction scores. It addresses a dimension of patient satisfaction that appears to garner little attention in healthcare contexts: emotional support. Though the literature strongly suggests that emotional support is correlated to overall patient satisfaction, few organizations have systematically attempted to understand the elements of outstanding emotional support. Research at a community teaching hospital in Ontario has shed light on the essential components of emotional support. In this article, a typology of emotional support is offered. With a better understanding of the components of emotional support, organizations may be able to undertake actions that could potentially improve patient satisfaction scores and, in turn, the overall quality of patient care.

Can’t Get No Satisfaction: Examining the Link between Patient Satisfaction and CEO Compensation

As annual public sector health care expenditures continue to increase in developed countries, governments struggle with how to measure the value-for-money they are receiving. Hospital performance is often viewed solely in research through the lens of economic indicators, with limited credence given to other contextual influencers. However, given the articulated focus of hospital mission, vision and value statements on prioritizing the patient, this research explores whether not-for-profit hospital CEOs are actually being compensation for high patient satisfaction factors; in effect, are hospital CEOs rewarded for meeting patient needs? Through an examination of 62 small, medium and teaching hospitals in Ontario, Canada from 2003 to 2006, we discover that patients’ satisfaction with their hospital experience is a predictor of the level of compensation of the hospital CEO. We further note that financial performance of the hospital does not appear to moderate this relationship. Given the increasing public po...

Recognizing and Responding to Uncertainty: A Grounded Theory of Nurses’ Uncertainty

There has been little research to date exploring nurses' uncertainty in their practice. Understanding nurses' uncertainty is important because it has potential implications for how care is delivered. The purpose of this study is to develop a substantive theory to explain how staff nurses experience and respond to uncertainty in their practice. Between 2006 and 2008, a grounded theory study was conducted that included in-depth semi-structured interviews. Fourteen staff nurses working in adult medical-surgical intensive care units at two teaching hospitals in Ontario, Canada, participated in the study. The theory recognizing and responding to uncertainty characterizes the processes through which nurses' uncertainty manifested and how it was managed. Recognizing uncertainty involved the processes of assessing, reflecting, questioning, and/or being unable to predict aspects of the patient situation. Nurses' responses to uncertainty highlighted the cognitive-affective strategies used to manage uncertainty. Study findings highlight the importance of acknowledging uncertainty and having collegial support to manage uncertainty. The theory adds to our understanding the processes involved in recognizing uncertainty, strategies and outcomes of managing uncertainty, and influencing factors. Tailored nursing education programs should be developed to assist nurses in developing skills in articulating and managing their uncertainty. Further research is needed to extend, test and refine the theory of recognizing and responding to uncertainty to develop strategies for managing uncertainty. This theory advances the nursing perspective of uncertainty in clinical practice. The theory is relevant to nurses who are faced with uncertainty and complex clinical decisions, to managers who support nurses in their clinical decision-making, and to researchers who investigate ways to improve decision-making and care delivery.

Cost-effectiveness analysis of a system-based approach for managing neonatal jaundice and preventing kernicterus in Ontario.

To evaluate the incremental cost-effectiveness of a system-based approach for the management of neonatal jaundice and the prevention of kernicterus in term and late-preterm (≥35 weeks) infants, compared with the traditional practice based on visual inspection and selected bilirubin testing. Two hypothetical cohorts of 150,000 term and late-preterm neonates were used to compare the costs and outcomes associated with the use of a system-based or traditional practice approach. Data for the evaluation were obtained from the case costing centre at a large teaching hospital in Ontario, supplemented by data from the literature. The per child cost for the system-based approach cohort was $176, compared with $173 in the traditional practice cohort. The higher cost associated with the system-based cohort reflects increased costs for predischarge screening and treatment and increased postdischarge follow-up visits. These costs are partially offset by reduced costs from fewer emergency room visits, hospital readmissions and kernicterus cases. Compared with the traditional approach, the cost to prevent one kernicterus case using the system-based approach was $570,496, the cost per life year gained was $26,279, and the cost per quality-adjusted life year gained was $65,698. The cost to prevent one kernicterus case using the system-based approach is much lower than previously reported in the literature.